Learning Objectives
By the end of this section, you will be able to:
- Define psychoanalytic theories and therapies
- Identify nursing applications of psychoanalytic theories and therapies
Dr. Sigmund Freud (1856–1939) was the founder of psychoanalysis and noted for his theory that provides explanation of mental health, associated influences, and treatments (Mcleod, 2024b). Freud’s work on the ego defense mechanisms contributed significantly to the nurse’s work in therapeutic communication with clients.
Definitions
Freud’s psychoanalytic theory reaches into several areas of mental health and illness. Each area influences the client’s experience and leads the practitioner to investigate or assess the areas where distress originates, such as components of the personality and levels of consciousness. The nurse’s understanding of personality development can bring insight to nursing approaches and provide the basis for person-centered care.
Personality Development and Levels of Consciousness
Freud theorized that personality develops between the first and fifth years of life and believed that the person’s manner of being was set by this age. Freud thought the personality was controlled by the mind and that the mind had a structure that included three elements: the id, the ego, and the superego. Each element has a specific function.
Freud often used the description of an iceberg to visualize the mind; only a tenth of the mind is conscious, while the other 90 percent of the mind is unconscious. The awareness of one’s own existence, sensations, thoughts, and surroundings is consciousness. It is the part of the mind comprising psychic material of which the individual is aware. Whereas, unconsciousness is all the repressed memories, thoughts, and unacceptable feelings a person may have. The unconscious cannot be recalled without a trained therapist. Between these areas, Freud conceptualized the preconscious mind where thoughts and feelings are available to the conscious mind though not currently being applied (Mcleod, 2024b).
Id
The id is the part of the personality that is the most primitive and exists in infants. The id drives the instincts, reflexes, and needs. It lacks logic and cannot solve problems. It is often manifested by instinctive behaviors that all humans have to communicate and relieve stress and discomfort. Examples are crying, gagging, laughing, and coughing. The id strives to have all needs in check or to reach a sense of pleasure. Once the needs are met, the id-driven behaviors cease. There are other tensions or stresses that cannot be satisfied by these instinctive measures, such as anxiety. At the point of personality development, around the age of two, the ego takes over (Erwin, 2002).
Ego
The ego is both physiological and psychological and maturity often emerges around the fourth or fifth year of development. The ego is the part of the personality that experiences, reacts to, and negotiates with the outside world and thus mediates between the primitive drives of the id and the demands of the social and physical environment. Freud labeled this process that the ego goes through reality testing, meaning that it satisfies the id through manners that are appropriate and it weighs the positives and negatives of an id demand before reacting.
When the id surfaces that a person is hungry, for example, and wants to be fed to satisfaction, their ego enters and staves off the id with delayed gratification. The ego then synchronizes the id, reality, and the superego to manifest behaviors that are expressive. The ego therefore negotiates with the id to please the superego and is a learned component of the personality that contributes social expectations to meeting demands of reality.
Superego
The superego is the moral compass for the personality, the conscience of the person. The superego is the part of the personality representing the conscience, formed in early life by internalization of the standards of parents and other models of behavior. It echoes the good and bad learned from the primary caregiver from birth on. The problem with the superego is that it projects the ideal, not the realistic, striving for perfection in modeling learned responses. If a person has a strong superego, they may exhibit this through perfectionistic tendencies by being critical of themselves and others, and suffering from feelings of inferiority. Figure 2.2 and Figure 2.3 show how the id, ego, and superego relate to each other.
Another area of Freud’s theory is the psychosexual stages of development, which proposes that childhood experiences shape the adult personality and can underlie mental health problems. Freud created these stages and believed every human developed through these stages. It is important to understand these stages as nurses care for children and adults to assess development. The stages of psychosexual development are summarized in Table 2.1.
| Stage | Age (Years) | Erogenous Zone | Major Conflict | Adult Fixation Example |
|---|---|---|---|---|
| Oral | 0–1 | Mouth | Weaning off breast or bottle | Smoking, overeating |
| Anal | 1–3 | Anus | Toilet training | Neatness, messiness |
| Phallic | 3–6 | Genitals | Oedipus/Electra complex; identify with gender role | Vanity, overambition Difficulty with relationships |
| Latency | 6–12 | None | Social interaction | None |
| Genital | 12+ | Genitals | Intimate relationships | None |
Psychoanalytic Theories Related to Stress Response
In Freudian theory, a defense mechanism—a thought, words, or a behavior prompted by the unconscious mind—surface when demands of reality cannot be met by the person. Defense mechanisms are essentially stress responses. In the short-term, defense mechanisms reduce anxiety and provide a buffer to stressful situations. If relied upon longer term, however, defense mechanisms can result in ineffective coping and contribute to mental illness (Ito & Matsushima, 2017).
Freud believed that all defense mechanisms were rooted in anxiety. The environments in which all humans live have stressors that threaten, create pain, or create tension. The defense mechanism seeks to decrease the threat, stress, pain, or tension. Defense mechanisms like denial or distortion of reality keep reality less threatening. While some defense mechanisms are necessary to live in a healthy emotional manner, too many can cause problems with healthy adjustments and personal growth. Table 2.2 summarizes common ego defense mechanisms.
| Mechanism | Rationale | Example |
|---|---|---|
| Displacement | Transferring unacceptable feelings to another situation or person | A client criticizes the nurse after becoming angry with the physician. |
| Reaction formation | Exhibiting opposite behavior to disguise underlying feelings | A person who worries about their own alcohol use offers to speak against drinking at a school. |
| Undoing | Acting in a way that cancels or makes up for another behavior | A person brings their partner a gift after having an argument. |
| Projection | Assigning blame or responsibility to others for thoughts/behaviors unacceptable to self | A teenager states he would not have used tobacco if his brother did not bring it into the home. |
| Denial | Rejecting the truth to delay acceptance of reality | Someone receives news of a loved one involved in a traffic accident and exclaims, “Oh no! That can’t be true!” |
| Regression | Exhibiting behaviors usually seen at an earlier stage of development when the current problem did not exist | A preschool-aged child begs for a bottle when the parents are absent. |
Two other areas of Freud’s psychoanalytic theory that are helpful to nursing are the concepts of transference and countertransference. An unconscious feeling the client has toward another (such as a health-care worker) that is originally based on a childhood experience with an important person in their life is transference. For example, the nurse’s mannerisms may prompt unconscious recall for the client of positive or negative experiences from a past relationship, which influences the client’s response to the nurse. In nursing practice, the nurse should consider the concept of transference when recognizing and analyzing cues during client interaction. Whereas countertransference is the unconscious feeling the health-care worker has toward the client. If the client reminds the health-care worker negatively of someone they know, this can cause a problem with therapeutic communication and relationship. The nurse may also feel protective or affectionate toward the client, based on unconscious feelings from a past relationship. Feedback from nursing peers and mentors is very important, as is the nurse’s need for self-reflection and supervisory assistance so that the therapeutic relationship remains strong and client care is optimal. In all nurse-client interactions, nurses should strive to avoid personalizing clients’ behaviors and remarks.
Nursing Application of Psychoanalytic Theories
Because Freud’s theory discusses the complex human personality and how it is influenced by past events, it is helpful in nursing practice. It can provide a more in-depth comprehension of client behavior, emotions, development throughout stages of life, and motivations, which will improve the therapeutic relationship and enhance provision of care. By delving into unconscious processes, nurses are able to be more at one with clients, better understand their nonverbal behaviors, and clue into foundational mental health challenges. The theory reinforces the notion that humans and their environments are intermingled and that nurses should look at their clients in that broader context. The theory also emphasizes the need for focused listening, which can help nurses recognize the use of defense mechanisms as cues to the client’s feelings. The nurse can then reflect on what the client is saying to help them process their thoughts and emotions. Nurses also benefit from awareness of transference and countertransference in their interactions with clients, which improves nursing practice.